Pasadena Buddhist Temple
1993 Glen Avenue, Pasadena, California 91103
Telephone: (626) 798-4781 FAX (626) 345-9095
website: http://www.PasadenaBuddhistTemple.org
2016 MEMBERSHIP APPLICATION
Date:
□ Renewal
1] □ Mr.
□ Mrs. □ Miss.
2] □ Buddhist □ Non Buddhist
Name in Kanji [Optional]
___________
□ New Member
________________________________________________________
Last – First – Middle Name – Birth Date
_______________________________________________________________
Address _________________________________ City __________________ State ________ Zip _____
Phone _______________________ Mobile __________________ Email ______________________
SPOUSE:
1] □ Mr.
□ Mrs. □ Miss.
2] □ Buddhist □ Non Buddhist
Name in Kanji [Optional]
__________________________________________________________
Last – First – Middle Name – Birth Date
_______________________________________________________________
Phone _______________________ Mobile __________________ Email ______________________
CHILDREN:
Last Name
First
Middle
Birth Date
________________________________________________________________
□ Son □ Daughter
________________________________________________________________
□ Son □ Daughter
________________________________________________________________
□ Son □ Daughter
________________________________________________________________
□ Son □ Daughter
Membership Dues for 2016
□ Individual Membership $250
□ Family Membership $400
o Individual Member 85 years or older $200
□ Friend of Temple Membership $250
□ I wish to make my payments quarterly
Would you like to receive the “Hikari” Newsletter and other announcements by email ? □ Yes □ No
Would you like to make a donation ? □ Maintenance Fund $________
□ Wish List Fund $_______
□ General Fund
$ _______
Would you like to volunteer for a temple committee? □ Yes □ No Please list your occupation or work
experience: ______________________________________________.
Pasadena Buddhist Temple Tax ID No. 95-2251767